UPPER RESPIRATORY DISORDERS

Rhinitis
It is the inflammation of the nasal mucous
membrane.
Is a group of disorders characterized by inflammation and
irritation of the mucous membranes of the nose.
Often coexists with other respiratory disorders, such as
asthma.

By [Link] T( Bsc, MD) 1

 Types of Rhinitis
Allergic Rhinitis
 Is a symptomatic disorder of the nose induced after exposure to
allergens via IgE-mediated hypersensitivity reactions, which are
characterized by 4 cardinal symptoms of watery

Rhinorrhoea, nasal obstruction, nasal itching and sneezing.

 Occurs when the body’s immune system over-responds to

specific, non-infectious particles such as plant pollens, molds,
dust mites, animal hair, industrial chemicals (including tobacco
smoke), foods, medicines, and insect venom.

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 Allergic rhinitis---
 During an allergic attack, antibodies, primarily
immunoglobin E (IgE), attach to mast cells (cells that
release histamine) in the lungs, skin, and mucous
membranes.
 Once IgE connects with the mast cells, histamine,
opens the blood vessels and causes skin redness and
swollen membranes.
 When this occurs in the nose, sneezing and
congestion are the result.
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 Seasonal Allergic Rhinitis Or Hay Fever
 Also known as intermittent rhinitis
 It usually lasts less than 4 days a week
 The whole disorder lasts for about a month
 Usually caused due to exposure to seasonal Allergens like
pollen
 Occurs in late summer or spring when flowers bloom
 Hypersensitivity to ragweed, not hay, is the primary cause of
seasonal allergic rhinitis
 People with sensitivity to tree pollen have symptoms in late
march or early April; an allergic reaction to mold spores
occurs in October and November as a consequence of falling
leaves. By [Link] T( Bsc, MD) 4
 Perennial Allergic Rhinitis
 Also known as persistent rhinitis that occurs year-round and can
result from sensitivity to pet hair, mold on wallpaper,
houseplants, carpeting.

 Symptoms are often worse in the early morning or at night

 Symptoms last for more than 4 days, a week

 Whole disorder lasts for more than a month due to continuous
exposure to allergen e.g. House dust mite
 Air pollution such as automobile engine emissions can aggravate
allergic rhinitis.
 Although bacteria is not the cause of allergic rhinitis, allergic
condition may lead to higher bacterial levels, thereby creating a
condition that worsens the allergies.
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 Allergic rhinitis Pathophysiology

• The reaction occurs in 4 phases

1. Sensitization

2. Subsequent reaction to allergen – early phase

3. Late phase reaction

4. Systemic activation

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 Sensitization
 The respiratory mucosa of all human beings is exposed to
picogram to nanogram of pollen grain, dust mite fecal particles,
animal dander, and other proteins that are recognized by
antigen-specific IgE receptors on mast cells and basophils
 In atopics gets attached to antigen presenting cells Present in
the nasal mucosa
 These mucosally deposited antigens are processed by
Langerhans cells and antigen-presenting cells (APCs) in the
mucosal epithelium.
 These activated APC's stimulate hypersensitivity
 Mast-cell degranulation is the critical initiating event
of acute allergic symptoms
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 Early phase of allergic rhinitis
 This phase is associated with the rapid onset of acute
nasal symptoms (i.e. sneezing and Rhinorrhoea) and the
emergence of ocular symptoms (i.e. itching, redness,
and watering).
 These symptoms are caused by histamine release,
particularly from mast cells in the nasal mucosa.
 Mast cell degranulation plays a role
 Prostaglandin D2 / cytokines may play a role

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 Late phase response
 The late-phase reaction develops over a period of hours after exposure
to an allergen.
 It is characterized by cellular recruitment of basophils, neutrophil, T-
lymphocytes, monocytes, and eosinophils,
 This late-phase inflammatory reaction is associated with tissue
remodeling, tissue oedema, and the development and perpetuation of
nasal congestion,
 eosinophils chemo taxis is the main mechanism in the late reaction,
which is caused by chemical mediators produced in the early reaction.
 Several inflammatory cells, eosinophils, mast cells and T cells migrate to
nasal mucosa, break up and remodel normal nasal tissue, and these
processes result in nasal obstruction
 This phase is inflammatory in nature due to release of multiple
mediators, including cytokines, prostaglandins, and leukotrienes,
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 Systemic activation
 Increased production of eosinophils from bone
marrow
 The late-phase reactions and modifications in
tissue responsiveness contribute to bronchial
hyper responsiveness
 Bronchial asthma
 Nasal polyposis

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 Non-Allergic Rhinitis
 This form of rhinitis does not depend on the
presence of IgE and is not due to an allergic
reaction.
 The symptoms can be triggered by cigarette
smoke and other pollutants as well as strong
odors, alcoholic beverages, and cold.
 Other causes may include blockages in the
nose, a deviated septum, infections, and over-
use of medications such as decongestants.
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 Clinical manifestation
Nasal congestion
Rhinorrhoea(excessive nasal drainage, runny
nose)
Sneezing
Itching
Nasal discharge (purulent with bacterial rhinitis)
Pruritus of the nose, roof of the mouth, throat,
eyes, and ears and headache.
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 DIAGNOSIS OF AR
 The diagnosis of AR is based on a typical history of allergic
symptoms and diagnostic tests.
 When 2 or more symptoms out of watery Rhinorrhoea,
sneezing, nasal obstruction and nasal pruritus persist for ≥1
hour on most days, AR is strongly suspected
 Skin testing
Skin testing is the most important to find offending allergens.
There are various testing methods including the scratch,
prick/
puncture, intradermal and patch tests.
 The radioallergosorbent test (RAST);Serum specific IgE level
 Multiple allergen simultaneous test
By [Link] T( Bsc, MD) (MAST); uses a photo 13
 TREATMENT OF ALLERGIC RHINITIS

• Requires a stepwise approach depending on the severity

and duration of symptoms.
• Treatment options for AR consist of
a) Allergen avoidance,
b) Pharmacotherapy,
c) Immunotherapy and
d) Surgery.

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 Pharmacotherapy
An over-the-counter (OTC), non-sedating antihistamine
 Competitively inhibit the interaction of histamine
with H1 receptors.
 They prevent and relieve nasal itching, sneezing,
and Rhinorrhoea, and ocular symptoms,
e.g.
 Loratadine 10 mg once daily
 Desloratadine 5 mg once daily
 Cetirizine 10 mg once daily or divided BID
 Levocetirizine 5 mg once daily in the evening

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 Intranasal corticosteroids

 Are potent inhibitors of the late-phase allergic

reaction in AR.
 They inhibit recruitment of Langerhans cells,
macrophages, mast cells, T cells, and eosinophils into
the nasal mucosa
 They control itching, sneezing, Rhinorrhoea, and
stuffiness
E.g.
 Beclomethasone dipropionate 2 sprays /day
 Fluticasone (Flonase), 1–2 sprays /day
By [Link] T( Bsc, MD) 16
 Decongestants
 Decrease swelling of the nasal mucosa which, in turn,
alleviates nasal congestion
e.g. Oxymetazoline nasal spray
Pseudoephedrin 60 mg every 4-6 h
e pills 120mg every 12h
240mg once daily

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 Nursing Management
Encasing the mattress, pillow and duvet in impermeable covers
Washing all bedding in hot water
Replacing carpets with linoleum or wooden flooring
Minimizing the use of upholstered furniture
Keeping dust-accumulating objects in cupboards
Washing curtains in hot water or replacing curtains with blinds
Washing soft toys in hot water or freezing them.

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 Sinusitis
Four pairs of paranasal sinuses

1. Frontal-above eyes in
forehead bone

2. Maxillary-in cheekbones,
under eyes

3. Ethmoid-between eyes and

nose

4. Sphenoid-in center of skull,

behind nose and eyes
By [Link] T( Bsc, MD) 19
 Sinusitis---
An acute inflammatory process
involving one or more of the
paranasal sinuses.

A complication of 5%-10% of URIs in

children.

Persistence of URI symptoms >10

days without improvement.

Maxillary and ethmoid sinuses are

most frequently involved.
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 Types of Sinusitis
It is typically classified by:_
 Duration of illness (acute vs. Chronic)
 Etiology (infectious vs. Noninfectious)
 Pathogen type (viral, bacterial, or fungal)

1. Acute Sinusitis – respiratory symptoms last longer than 10 days

but less than 30 days.
2. Sub acute sinusitis – respiratory symptoms persist longer than
30 days without improvement.
3. Chronic sinusitis – respiratory symptoms last longer than 120
By [Link] T( Bsc, MD) 21
days.
 Pathophysiology of sinusitis
Rhinitis or abrupt pressure changes (air planes, diving) or dental
extractions or infections.
Inflammation and edema of mucous membranes lining
the sinuses cause obstruction.
With inflammation, the mucosal lining of the sinuses produce
mucoid drainage. Bacteria invade and pus accumulates inside
the sinus cavities.
Postnasal drainage causes obstruction of nasal passages and
an inflamed throat.

If the sinus orifices are blocked by swollen mucosal lining, the

pus cannot enter the nose and builds up pressure inside the
sinus cavities
By [Link] T( Bsc, MD) 22
 Predisposing Factors
Allergies,
Cold weather
High pollen counts
Day care attendance
Smoking in the home
Reinfection from siblings
Anatomical: septal deviation, nasal
deformities, nasal polyps
Mucociliary functions: cystic fibrosis, immotile
cilia syndrome.
Systemic disease: immune deficiency.: DM,
AIDS,
Neoplasia By [Link] T( Bsc, MD) 23
 Etiology
Acute sinusitis Chronic sinusitis
Str. pneumoniae %41 Anaerob bacteria:
H. influenzae %35 Bactroides,
M. catarrhalis %8 fusobacterium
Others %16 S. Aureus
 Strep. pyogenes Strep. Pyogenes
 S. aureus Str. Pneumoniae
 Rhinovirus Gram (-) bacteria
 Parainfluenzae fungi
 Veilonella, peptokoccus
By [Link] T( Bsc, MD) 24
 Signs and Symptoms
Headache, congestion, facial pain, fatigue, and cough,
Purulent nasal discharge.
Pain over the region of the affected sinuses
If a maxillary sinus is affected, the patient
experiences pain over the cheek and upper
teeth.
In ethmoid sinusitis, pain occurs between and
behind the eyes.
Pain in the forehead typically indicates frontal
sinusitis.
Fever may be present in acute infection, with or without
generalized fatigue and foul breath.
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 Diagnosis of sinusitis
History ;persistent symptom of URI and physical findings
Radiographic studies
Opacification and mucosal thickening air filled
level
Others :
Translumination of sinus cavity
Sinus aspirate culture
Nasal endoscopy
If repeated episodes occur:-
 x-ray examination
 computed tomography (CT) scan
 magnetic resonance imaging (MRI)
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 Treatment of Sinusitis
Nondrug measures :
Maintain adequate hydration(drink 6-10glasses of liquid )
Personal Steam vaporizer
Apply warm facial packs (warm wash cloth, hot water bottle)
Saline irrigation lavage (1/4 teaspoon salt dissolved in 1cup of
water )
Sleep ahead of bed elevated
Adequate rest
Avoid cigarette smoke and extremely dry or cool air
By [Link] T( Bsc, MD) 27
 Drug Treatment
Antibiotics
First-line:
Amoxicillin, 1.5 to 3.5 g/d divided 2 or 3 times daily)
 Trimethoprim–sulfamethoxazole 800/160 mg twice daily
Second-line:
Amoxicillin–Clavulanate (500/125 mg 3 times daily)
Second- or third-generation cephalosporin
Cefuroxime, 250 or 500 mg twice daily,
Doxycycline 200 mg on first day then 100 mg twice daily
for 2 to 10 days
By [Link] T( Bsc, MD) 28
Antibiotics----
Macrolides :
Clarithromycin, 500 mg twice daily or
Azithromycin, 500 mg daily for 5 days
Fluoroquinolones :
Ciprofloxacin, 500 twice a day or
Levofloxacin, 500 mg once daily
Oral antihistamines :Loratadine, 10 mg daily
Nasal decongestant: Xylometazoline intranasally, 2 to 3 sprays
every 8 to 10 hr.
Nasal steriods :Fluticasone, 2 puffs) intranasally [200 µg] daily
Acetaminophen or ibuprofen is given for pain and fever.
By [Link] T( Bsc, MD) 29
 Nursing management

Patient teaching self care

 Instruct patient to blow the nose gently and to use tissue to
remove the nasal drainage.
 Increasing fluid intake,
 Applying local heat (hot wet packs), and
 Elevating the head of the bed promote drainage of the
sinuses.
 Instructs the patient about the importance of medication
regimen.

By [Link] T( Bsc, MD) 30

 Tonsillitis
Tonsils are protective (lymph) glands that are situated
on both sides in the throat.
The tonsils constitute an important part of the body's
immune system and are vital defense organs.
They protect the body from bacteria and viruses by
fighting these as soon as they enter the body (via the
oral / nasal cavity).

By [Link] T( Bsc, MD) 31

Inflammatory process of the mucosa and
structures of the pharyngo-tonsillar area,
usually of infectious origin
Tonsillitis is contagious.
It affects all ages, but is most common in
children between ages 5 and 10

By [Link] T( Bsc, MD) 32

Tonsillitis ---

By [Link] T( Bsc, MD) 33

 Clinical Manifestations

 Throat pain, either mild or severe.

 Swallowing with difficulty.
 Odynophagia, pharyngeal exudate, anterior
cervicolateral lymphadenopathy, scarlet rash and
headache
 Chills and fever as high as 104° F (40° C) or more.
 Swollen lymph glands on either side of the jaw.

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 Ear pain.
 Cough (sometimes).
 Vomiting (sometimes).
 Refusal to eat in a very young child.
 Erythema,
 Edema,
 Ulcer or vesicles

By [Link] T( Bsc, MD) 35

 Causes of Tonsillitis
 Viruses: Rhinovirus, adenovirus, influenza virus,

Para influenza virus,Coxsackie virus and Epstein-Barr virus

 Aerobic Bacteria: GABHS and other streptococcal species, Neisseria gonorrhoeae,

Corynebacterium diphtheriae.

 Yeast :Candida species.

Spirochetes:Treponema pallidum (syphilis)

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Causes ----

By [Link] T( Bsc, MD) 37

 Assessment and Diagnostic Findings

History :look at throat to see

red and swollen tonsils with spots or
sores.
Throat culture: rapid strep test
Blood test ;done to confirm
presence of infection
By [Link] T( Bsc, MD) 38
 Medical Management
 Bed rest, except to use the bathroom, is necessary
until fever subsides.
DIET
 Supportive measures include Increase all fluid intake. While the
throat is very sore, use liquid nourishment, such as milk shakes,
soups, and high-protein fluids (diet or instant-breakfast milk
drinks).

Viral tonsillitis is not effectively treated with antibiotic

therapy.
Tonsillectomy if complicated
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 Antibiotic treatment of choice
• Penicillin V: <12 years or <27 kg: 250mg / 12h 10 days
>12 years or >27 kg: 500mg / 12h 10 days
• Penicillin G Benzathine:
<12 years or <27 kg: 600.000 UI, single dose
>12 years or >27 kg: 1.200.000 UI, single dose
• Amoxicillin: 50mg /kg/day, every 12-24 hours, 10 days, with a
maximum dose of 500mg /12h or 1g/24h.
• Mediated by IgE:
- Azithromycin: 20mg/kg /day, once a day, 3 days (maximum
500mg/day)
- Clindamycin: 20-30mg/kg /day, every 8-12h, 10 days
(maximum 900mg/day).
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Indications for tonsillectomy
Recurrent tonsillitis (more than seven per year
Persistent, chronic tonsillitis
Recurrent peritonsillar abscess with previous history of
recurrent or persistent tonsillitis.
Unilateral tonsillar hypertrophy.
Hemorrhagic tonsillitis.
Chronic tonsillolithiasis.
Nasal obstruction with speech abnormalities, orodental
abnormalities.

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 Complications of tonsillitis
• Classified into suppurative and nonsuppurative complications.
• The nonsuppurative complications include
Scarlet fever,
Acute rheumatic fever, and
Post-streptococcal glomerulonephritis.

Suppurative complications include

Peritonsillar, parapharyngeal and retropharyngeal
abscess formation.

By [Link] T( Bsc, MD) 42

 Pharyngitis
ACUTE PHARYNGITIS: is a sudden painful
inflammation of the pharynx, the back portion of the
throat that includes the posterior third of the tongue, soft
palate, and tonsils.
It is commonly referred to as a sore throat
Causes
– Viral infection- most common(adenovirus, influenza
virus, Epstein-Barr virus, and herpes simplex virus)
– Bacterial infection-Group A beta-hemolytic
By [Link] T( Bsc, MD) 43
 UPPER RESPIRATORY DISORDERS….
Pathophysiology
Viral/ strep throat infection
The body responds by triggering an inflammatory response
in the pharynx.
This results in pain, fever, vasodilation, edema, and tissue
damage, manifested by redness and swelling in the tonsillar
pillars, uvula, and soft palate.
A creamy exudate may be present in the tonsillar pillars
If caused by GA hemolytic streptococcus- it may be severe
If caused by uncomplicated virus- may be subside
promptly(3 to 10 days after the onset).
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UPPER RESPIRATORY DISORDERS….
Complications

Sinusitis

Otitis media

Peritonsillar abscess

Mastoiditis

Cervical adenitis

In rare cases, the infection may lead to bacteremia,

pneumonia, meningitis, rheumatic fever, and nephritis.
By [Link] T( Bsc, MD) 45
UPPER RESPIRATORY DISORDERS….

Clinical features
Fiery-red pharyngeal membrane and tonsils
Lymphoid follicles that are swollen and flecked with
white-purple exudate, and enlarged
Tender cervical lymph nodes
No cough
Fever
Malaise
Sore throat

By [Link] T( Bsc, MD) 46

UPPER RESPIRATORY DISORDERS….

By [Link] T( Bsc, MD) 47

 UPPER RESPIRATORY DISORDERS….
• Assessment and dxs
Accurate diagnosis of pharyngitis is essential to determine
the cause (viral or bacterial)
Newer and more rapid diagnostic tests (eg, the rapid
streptococcal antigen test (RSAT).
Medical mgt
For virus- supportive care
For bacterial-penicillin is a drug of choice if allergic and
resistance (clarithromycin and azithromycin) may be
used.
Analgesic medications, as prescribed( i.e. Aspirin or
acetaminophen)can be Bytaken
[Link] T( Bsc, MD) 48
 UPPER RESPIRATORY DISORDERS….
Nursing management
Instructs the patient to:_
Stay in bed during the febrile stage of illness and
Full course of antibiotic therapy
Preventive measures
 Not sharing eating utensils, glasses, napkins, food, or
towels; cleaning telephones after use
Using a tissue to cough or sneeze
Disposing of used tissues appropriately
 Avoiding exposure to tobacco and secondhand smoke.
By [Link] T( Bsc, MD) 49
 UPPER RESPIRATORY DISORDERS….
Chronic pharyngitis:- is a persistent inflammation of the
pharynx.
Types
 Hypertrophic: characterized by general thickening and
congestion of the pharyngeal mucous membrane
 Atrophic: probably a late stage of the first type (the
membrane is thin, whitish, glistening, and at times
wrinkled)
 Chronic granular (“clergyman’s sore throat”),
characterized by numerous swollen lymph follicles on the
pharyngeal wall

By [Link] T( Bsc, MD) 50

 UPPER RESPIRATORY DISORDERS….
Common in person :_
 work in dusty surroundings
 Use their voice to excess
 Suffer from chronic cough
 Habitually use alcohol and tobacco.
Clinical manifestation
 Sense of irritation or fullness in the throat,
 Mucus that collects in the throat and can be expelled by
coughing
 Difficulty swallowing.

By [Link] T( Bsc, MD) 51

 UPPER RESPIRATORY DISORDERS….

Medical management
Nasal congestion medications (ephedrine sulfate
(Kondon’s Nasal) or phenylephrine hydrochloride)
Antihistamine decongestant medications, such as
Pseudoephedrine.
For adults with chronic pharyngitis, tonsillectomy is an
effective option.
Nursing management
Avoid alcohol, tobacco, secondhand smoke, and exposure
to cold or to environmental or occupational pollutants.

By [Link] T( Bsc, MD) 52